Healthcare Provider Details

I. General information

NPI: 1275154890
Provider Name (Legal Business Name): ROBERT MICHAEL DIAZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2020
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 GASTON AVE
DALLAS TX
75246-2088
US

IV. Provider business mailing address

5735 GASTON AVE APT 120
DALLAS TX
75214-6448
US

V. Phone/Fax

Practice location:
  • Phone: 214-820-2362
  • Fax: 214-820-7272
Mailing address:
  • Phone: 432-352-2057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP10071715
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: